Comment on ‘A review of 145 234 ophthalmic patient episodes lost to follow-up’

Sir,

Davis et al¹ identify the importance of seamless transfer of outcome information from doctor to reception. In systems theory terms, they have demonstrated how information degrades with time and transfer. Errors generated by degradation lead to more work for staff. This has been termed ‘failure demand’ by systems design critic John Seddon.² He argues that separation of ‘back office’ and ‘front office’ functions is a prime cause of this failure. In the setting of Davis et al, the back office is the reception, where the doctor and patient are excluded from meaningful interaction, and the task is essentially purely administrative. This design arises out of a desire to minimise contact time with the customer in service organisations.³ This is because customers are a source of variation, which adversely affects ability to reliably maximise resource utilisation.

The alternative to this resource utilisation-optimised design is to aim for ‘flow optimisation’. This prioritises completing tasks in as few steps as possible. The authors have partly achieved this by ensuring that reception staff always complete the outcome process on the same day. However, a more flow-optimised design would have the outcome process completed within the consultation itself, either by an admin staff member in the room or by a well-designed IT solution completed by the doctor. The immediate objection to this use of staff time is to say that admin staff may be under-utilised and doctors over-utilised. The book ‘This is Lean’⁴ discusses this conflict between resource utilisation and flow optimisation. The argument is made that the most efficient organisations understand this conflict but prioritise flow optimisation because this tends to produce greater efficiencies overall.

The recent publication by the College, ‘The Way Forward’ (https://www.rcophth.ac.uk/standards-publications-research/the-way-forward/), highlights service delivery challenges in the context of significant predicted demographic change over the next 20 years. If managers and clinical leaders are to respond appropriately they need to learn to see the underlying principles behind their current service design and to know the alternatives. Learning from studies of service industries can help to achieve this.